Benefits of HBPC Training

SURVEY: Understanding COVID-19 in home-based care practices

Survey request

HCCI is sharing this request on behalf of our colleagues Drs. Christine Ritchie and Bruce Leff and the National Home-Based Primary Care Learning Network.

Dear Colleague,

We are researchers at Massachusetts General Hospital and Johns Hopkins University writing to alert you to a new research study supported by the National Home-Based Primary Care Learning Network.

We wish for you to take 10 minutes to help home-based primary care practices learn from each other during the COVID-19 pandemic.

This survey is being fielded to help increase our understanding of COVID-related practice challenges and the strategies used to overcome them.

The ultimate goal and benefit to you is to help home-based care practices learn from one another to navigate the current and potential future pandemics.

Our COVID-19 survey is strictly voluntary. Participation in the survey will determine consent. If particular practice leaders do not wish to complete the COVID-19 survey, they have the right to refuse without consequence. This one-time survey can be completed by anyone in your practice and should take 10 minutes or less to complete.

Please complete the survey HERE 

Please send your responses by Tuesday, June 9th 2020

Our goal is to quickly obtain and report back to you the findings from this survey so that you can use it in your practice.

Your participation in this research will make a huge difference. We thank you in advance for your help.

If you run into any technical difficulties completing this survey, please email our program manager, Naomi Gallopyn, at [email protected].

Christine Ritchie
Ken Minaker Endowed Chair in Geriatric Medicine
Research Director, Division of Palliative Care and Geriatric Medicine
Massachusetts General Hospital Mongan Institute

Bruce Leff, MD
Professor of Medicine
Johns Hopkins University of Medicine

HCCIntel Practice Management Tip of the Month Training Training & Education

Agendas for Interdisciplinary Team Meetings

Interdisciplinary team meeting

Interdisciplinary team (IDT) meetings improve staff communication, encourage teamwork, and promote optimal patient care and outcomes within house call programs. During the COVID-19 pandemic, IDT meetings are especially important for maintaining team cohesiveness. Following a structured meeting agenda can help maximize IDT meeting effectiveness. In addition, brief staff huddles can serve to supplement IDT meetings and address immediate concerns.

Sample IDT Meeting Agenda:

  1. Key Metrics – discuss outcomes and/or clinical quality metrics being used
  2. Hospitalizations – review recent hospitalizations, brainstorm solutions for future
  3. Case Management – social workers, pharmacists, clinical staff, and/or providers present complex cases to initiate action/planning for patient resources
  4. Announcements / Updates – address logistical or operational changes affecting the team
  5. Waste Identification – discuss process breakdowns/inefficiencies, assign team members to strategize solutions
  6. Recognition – encourage team members to acknowledge others who have gone above and beyond or highlight a team accomplishment to end the meeting on a high note

Effective IDT meetings are a proven way to optimize patient care and outcomes, but they require planning, commitment, and time. To access and download a copy of the full IDT sample agenda, click here (new users will need to complete a one-time registration).


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Keeping Humanity in House Calls: How One Question Can Change So Much

May 15, 2020

About the Article: HCCInsights sat down with Dr. Thomas Cornwell, Executive Chairman, Home Centered Care Institute, to learn how he keeps humanity in house calls, especially during the COVID-19 pandemic, when stress and feelings of isolation can be elevated in many patients and caregivers.

HCCInsights: What is key to keeping humanity in house calls – especially during COVID-19?  And, how do you draw out what’s going on with patients when you’re seeing them in a home setting?

Dr. Cornwell: Overall, it’s important to stay focused throughout on the geriatric 5Ms, which are Mind, Mobility, Medications (polypharmacy can be a problem and we need to be skilled at de-prescribing), Multi-complexity which is why most of these patients cannot leave the home, and the most important “M” of all, which is What Matters Most to the patient. We don’t just start with their conditions and symptoms.

What Matters Most is part of every house call I make. It’s important to make the patient feel valued and ensure they know there is a caring practitioner available to help them 24/7 whenever they have a problem. When you ask a patient what matters most to him or her, it also opens a window to their emotions. It can help you understand how they’re being affected by any given situation in their life, gauge their level of loneliness, identify whether they’re experiencing anxiety or changes due to things like COVID-19, and so on.

Understanding what matters to the patient helps guide all care. For example, if you find out that what matters most to your patient is avoiding the hospital, that piece of knowledge will help guide your decisions and the advice you offer because you’ll know to focus on things that can be accomplished within the home environment.

[Editor’s Note: See also the “4M’s” approach that appears in Age-Friendly Health Systems,” an initiative of The John A. Hartford Foundation and Institute for Healthcare Improvement in partnership with the American Hospital Association and Catholic Health Association of the United States.]

HCCInsights: You’ve mentioned that you like to ask new patients to talk about something they’re proud of.  Why is that such an important question?

Dr. Cornwell: It’s part of my approach to patient-centered care and establishing a relationship and moving it forward. Not surprisingly, most of the time, I hear they’re most proud of their children and grandchildren.

Some other examples also come to mind. Like I’ve had female patients in their 80s and 90s tell me about earning their Ph.D. back in the 1930s or 40s when it was an exceedingly rare achievement for women. It is incredible to hear their stories about what it was like breaking through the barriers they faced at the time.

I’ve also heard stories from someone who was a Top Gun pilot and another who was an Olympic athlete. Also, one of my patients worked with Neil Armstrong.  Another served as a military driver to Jacqueline Kennedy Onassis. Rather than starting with their problems, I start with their life highlights.

When patients begin to share some of their personal information, it also opens them up to sharing other things, like how their mood has been, whether they’ve been feeling depressed or anxious, and so forth. Talking with the patient about their feelings helps reinforce that I listen and care. It also helps me better understand my patient on a more personal level.

I actually started asking this question years ago after one of my patients with advanced dementia passed away. That patient was never able to talk with me, and it was only from his obituary that I learned he had been a famous inventor and past president of a national professional organization.

You know, much of the home-based patient population is currently comprised of members from “The Greatest Generation.” They are amazing people with amazing stories who have lived history, and I feel it’s important to affirm to both the patients and their families how great an honor it is to care for such remarkable individuals… and every one of them is remarkable.

HCCInsights: How do you stay engaged on a personal level with the patient’s caregivers?

Dr. Cornwell: There are multiple aspects to that. First, I intentionally praise the caregivers all the time. If it weren’t for caregivers and all the sacrifices they make, home-based primary care providers wouldn’t have jobs. It’s because of the caregivers that two to three million patients are being cared for at home today – patients who suffer the same degree of infirmity as the million or so patients who are in nursing homes. A major difference is 100% of nursing home patients have a provider in the nursing home, while only 15% of homebound patients have a provider that makes house calls.

It’s also important to acknowledge caregivers as the real heroes. They find themselves in nursing roles they never imagined being in and that they were never really trained to do. In fact, there’s often an incredible lack of training provided to caregivers when their loved one leaves the hospital and it can be overwhelming.

So, in addition to praising caregivers, we also do a lot of training around medication management, wound prevention and treatment, tube feeding, how to use oxygen equipment and walkers, and much more. Through training, we help them feel more confident and comfortable in their roles and we do it because we want them to know we’re in this together.

That’s an important thing for them to know because, as seen during a focus group with caregivers conducted in the past with the University of Illinois at Chicago, we learned it was vitally important to caregivers to know they were not alone and that a competent, caring provider was available 24/7 to assist them with care of their loved one. As we also know, there’s a real need in the human spirit to not feel alone and it’s especially true when we’re talking about caregivers for homebound patients.

Remember also that many of these caregivers are part of the “sandwich” generation, meaning they are taking care of their children and their parents simultaneously, and it’s amazing that without formal medical training, they are caring for such medically-complex patients so lovingly at home. Acknowledging their role and contributions, and providing training and emotional support, plays a big part in making it all work.

HCCInsights: What do you do when a patient is having a bad day?

Dr. Cornwell: The old cliché goes something like, “Hope for the best, plan for the worst.” I prefer to say, “Hope for the best, plan for the rest.” Plus, it even rhymes better!

On the patient’s “darker” days, in addition to the treatment I provide, I ask them again to tell me what they’re proud of in their lives. For example, I had one patient who had been repeatedly hospitalized for anemia. One day, as he was sitting in a wheelchair, in a vulnerable state, being taken care of by his son and daughter, I sensed his despair. So, I asked him, “Can you tell me something you are proud of?”

He paused and said, “You know, I’m proud of having been on Normandy Beach.” Then he went on to mesmerize me with a story from World War II about being on a Navy ship that was shelling the cliffs of Normandy when the ship got grounded. His platoon had to abandon ship and somehow miraculously survived. Sometime later, while stationed in the Pacific, my patient hurt his ankle and couldn’t join his fellow sailors on one of their missions – a mission in which their ship was torpedoed. Lives were lost, and he didn’t know who lived or died.

In the end, the most amazing thing about this man’s story was that his children had never heard it. He had never talked about it before. Apparently, he had thrown his medals from his time in the service away ─ maybe he suffered from PTSD before we knew what PTSD was. But his children made the effort after hearing his story to call the VA, which replaced his medals. They also found an article online about the ship that had been torpedoed. One of his best friends from the war was interviewed in the story, so he learned his friend had not been among those who perished.

All this came from just one question and at the end of that visit, what did I tell my patient?  I said, “Thank you for my freedom.” It was such a blessing to be able to be a part of that with him and his family.

HCCInsights: How has the COVID-19 pandemic affected your ability to keep humanity in house calls, especially when you’re doing so many virtually right now through telehealth?

Dr. Cornwell: Over the past 45 days or so, 90% of my visits have been through telehealth. I have done face-to-face visits when procedures such as tracheostomy and g-tube changes were required, but in full Personal Protective Equipment (PPE), mainly to protect the patient.

I have been surprised at how effective audio and visual telehealth visits have been. These are supported by the fact that, because of the complexity of our patients, many have blood pressure cuffs and pulse oximeters at home ─ so I can get vitals. Using the audio/visual technology, I can also see how they are looking, how their leg edema or wounds are doing and so on.

Two cases have been particularly rewarding. One patient was at an assisted living facility and I was able to do a three-way video call with the daughter at her home and the nurse with the patient at the facility. It was the first time the patient was able to see her daughter in over a month, and I just sat back and let them get caught up for the first five minutes of the visit. Another younger patient had been having great difficulties. I was able, with telehealth, to make weekly virtual visits that I could not have done if I had to drive to his home every week. It really helped improve his care.

Overall, the patients and caregivers have greatly appreciated the telehealth visits. These visits, of course, are not a long-term replacement for in-home visits but complement them, especially during this challenging time.

HCCInsights: Being a house call provider is obviously not easy, so what is it about home-based primary care, and that human aspect of it, that makes it so rewarding?

Dr. Cornwell: There are many things that make home-based primary care rewarding.  As a provider, I am meeting patients in their home, seeing their artwork, their photographs, and their environment. I am seeing who they are through a completely different lens versus seeing patients in a nursing home or other clinical setting where it’s so much easier to lose the personal touch.

When you see patients in their homes, you must slow down. Home-based care is a 100% immersive experience and you learn an enormous amount about a patient within seconds, even before a single word is exchanged.

This type of care also requires the provider to be humble, as the traditional “balance of power” is shifted to the patient and family when you are in their home versus an office or clinic setting.  At the same time, you need to be sensitive to cultural differences which is another part of keeping humanity in the house call.

The home environment itself is also a factor in the patient’s overall well-being that must be considered. For example, if the patient is someone in a hoarding situation who also has problems with leg swelling, you may find that their environment makes it difficult to elevate their legs, making their condition worse, and so you must deal with that.

Finally, the difference you can make in the lives of homebound patients is unbelievable. Most homebound patients receive fragmented care, often through repeated hospitalizations. For elderly patients with multiple chronic problems, not only is this poor care, it is expensive care. Home-based primary care makes such a profound difference in their lives and the lives of their caregivers, by giving patients quality, longitudinal primary care in their homes and dramatically reducing hospitalizations and going to nursing homes.

HCCInsights: How do you manage conflicting family dynamics when they arise?

Dr. Cornwell: Family dynamics can be challenging. That’s another unique aspect of house calls: it’s impossible to ignore certain situations. If a patient is having difficulty getting medicine or food, for example, the provider needs to step in and ensure the right services are being used.

Conflicts about the patient’s plan of care sometimes must be mediated as well. For example, I like to start with “agreement” among the family members. I might first ask the family members, “Do we all agree that we love Mom?” Once that is agreed on, we move on to treatment decisions where there may be conflicts and try to reach agreement. This is always done by repeatedly asking the family what they think their mom would say if she could speak right then.

Focusing on what matters most to the patient can help reduce emotional tensions and guilt that can arise in making difficult decisions for loved ones.

HCCInsights: Though it’s not often mentioned in technical healthcare conversations, “love” seems to be behind much of what you’ve talked about today. What has your role as a home-based care provider taught you about love?

Dr. Cornwell: It has taught me that, of all the things the patient’s caregivers are doing and responsible for, their single most important responsibility is to provide “Vitamin L” – or “Love.” Love is what keeps people going, sometimes for years longer than anyone would expect, and that is particularly true, for example, with patients who have dementia.

So, I encourage the caregivers and cheer them on because it’s their love for the patients that’s making the difference.

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CMS releases additional interim final rule, creating more telehealth flexibility and featuring significant regulatory changes

On April 30, 2020, the Centers for Medicare and Medicaid Services (CMS) released a second Interim Final Rule with new flexibilities and changes relevant to home-based medical care providers. The changes in this most recent Interim Final Rule are effective immediately, with many modifications retroactively effective as of 3/01/2020. These include the following:

  • CMS increased the payment for telephone Evaluation and Management (E/M) visits to be similar to payment for an office visit. This was done to accommodate providers who are caring for patients without access to two-way audio and video technology. When seeking reimbursement for telephone visits, physicians and other qualified healthcare professionals (i.e., nurse practitioners and physician assistants) may use the Telephone E/M CPT codes listed below. CMS also designated these telephone E/M services as “Medicare telehealth services,” and as such, they will require modifier 95.
    • CPT 99441Telephone E/M 5-10 minutes; Increased Non-Facility Payment $46.19; wRVU 0.48
    • CPT 99442Telephone E/M 11-20 minutes; Increased Non-Facility Payment $76.15; wRVU 0.97
    • CPT 99443Telephone E/M 21-30 minutes; Increased Non-Facility Payment $110.43; wRVU 1.50
  • In addition, the following services can also now be billed when using audio only:
    • Advance Care Planning (CPT 99497, 99498)
    • Annual Wellness Visits (HCPCS G0438, G0439)
    • Smoking Cessation Services (CPT 99406, 99407)
    • Alcohol and/or substance abuse (other than tobacco) structured assessment (e.g., AUDIT*, DAST**), and brief intervention services (HCPCS G0396, G0397)
    • Annual Alcohol Misuse Screening and Counseling (HCPCS G0442, G0443)
    • Annual Depression Screening (HCPCS G0444)
    • Chronic Care Management (CCM) Care Planning Services; please note this service is only to be used one time for new patients or patients who are not seen within a year when first enrolled in CCM (HCPCS G0506)

*Drug Abuse Screening Test
**Alcohol Use Identification Test

  • Be aware Medicare has designated additional services, e.g., psychotherapy and other therapy-related, nutrition, and education services, that allow for payment when provided via audio-only telehealth. To review the full list of Medicare audio-only telehealth services, visit the Medicare list of telehealth services.
  • The home and domiciliary E/M codes still require a two-way audio and video telecommunication method. Please review the CMS Fact Sheet and the revised FAQ that was released on 4/30/2020 for additional details.

Additional Key Updates:

  • CMS has officially adopted the regulation allowing for nurse practitioners, physician assistants, and clinical nurse specialists to order, establish and monitor plans of care, and certify and re-certify patients for home health services as mandated under the CARES Act. This change is permanent and applies to any service provided on or after 3/01/2020. (Click here for a guide to the CARES Act.)
  • CMS finalized on an interim basis that they will not enforce the clinical indications for therapeutic glucose monitors and they’re not subject to National Coverage Determinations (NCDs) and Local Coverage Determinations (LCSs). CMS had previously finalized on an interim basis that they will not enforce the clinical indications for respiratory devices, anticoagulation management, and infusion pumps. CMS did remind clinicians that services must be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member to be paid under Medicare. Physicians, practitioners, and suppliers are required to continue documenting the medical necessity for all services.
  • CMS waived the 16-day minimum requirement to bill for Remote Patient Monitoring (RPM) services, but only for patients who have suspected or confirmed COVID-19. In such cases, CMS recognized the value of short-term monitoring (no less than two days) for acute conditions and is allowing payment for CPT codes 99453, 99454, 99091, 99457, and 99458.
  • Until now, CMS used only its rulemaking process to add new services to the list of approved Medicare telehealth services. However, CMS is changing its process during the Public Health Emergency and will add new telehealth services on a sub-regulatory basis.
  • CMS waived some restrictions on the types of healthcare professionals that can furnish Medicare telehealth services for the remainder of the Public Health Emergency. Physical therapists, occupational therapists, and speech-language pathologists are now added to the list of eligible providers, which had already included physicians, nurse practitioners, physician assistants, licensed clinical social workers, and clinical psychologists. These providers can bill for telehealth services subject to the scope of practice laws.
  • CMS will no longer require a practitioner’s written order for patients to receive a COVID-19 test or other certain testing (e.g., serology testing) to diagnose and treat COVID-19. Pharmacists can also now perform COVID-19 tests if they’re enrolled in Medicare as a laboratory. Additionally, pharmacists can work with qualified healthcare professionals who are credentialed to bill Medicare to provide assessment and specimen collection services relating to a COVID-19 diagnosis. The physician or other qualified healthcare professional can bill Medicare for the test. This allows for parking-lot test sites and more rapid testing. (This is subject to state scope of practice laws.)
  • CMS is allowing hospitals to bill as the originating site for telehealth services, even if the patient is located at home. This applies to hospital-based practitioners for Medicare patients who are registered as hospital outpatients. This may be impactful for Hospital at Home® providers.
  • CMS is adjusting the financial methodology used for COVID-19 costs incurred by Accountable Care Organizations (ACOs) so they will be treated equitably regardless of the extent to which their patient populations are affected by the pandemic. ACOs can also forgo the annual application process; if their participation is set to end this year, they have the option to extend for another year. ACOs that are required to increase their financial risk during the current agreement period will have the option to maintain their current risk level for next year, instead of advancing automatically to the next risk level. CMS also includes virtual services, including virtual check-ins, remote evaluations, and telephone E/M services, as primary care services considered for beneficiary attribution.
  • CMS announced a new Coronavirus Commission for Safety and Quality in Nursing Homes. Read the Fact Sheet here.

Disclaimer: This information is current as of 5/05/2020. COVID-19 guidelines are changing daily. Please note for the purposes of the Home-Based Primary Care (HBPC) population: The Home Centered Care Institute (HCCI) focuses its content on CMS guidelines relevant for traditional Medicare billing. It’s always recommended to check with local MACs for specific guidance for your geographic region. Medicare Advantage and commercial payor policies will vary.